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LICENSE RENEWALMail this form and a separate check or money
order (do not send cash) with the applicable fee for each renewal
tothe address above. Make payable to the Board of Barbering &
Cosmetology (Incomplete forms will not be processed).
LICENSEE INFORMATION
License Type & Feeif postmarked If postmarked on
or before after
expiration date: expiration date:
Cosmetologist $50.00 $75.00Barber $50.00 $75.00Electrologist
$50.00 $75.00Manicurist $50.00 $75.00Esthetician $50.00
$75.00Establishment $40.00 $60.00Mobile Unit $40.00 $60.00
License NumberLetter(s):
Numbers:
Last 4 digits of your Social Security Number:(not required for
establishments)
Date of Birth:(not required for establishments)
- -Month Day Year
Last Name First Name Middle Name
Salon Name (if applicable)
If your address has changed do you want the Board to update our
records with your current address? Yes N
Important Notice: Changing the address on an establishment or
mobile unit is prohibited without applying for a newlicense;
contact the Board or visit the Board’s Web site to acquire an
establishment application.
Current Address City
Phone Number( )
Email Address (not required) State Zip Code
IMPORTANT INFORMATION (Please Read Carefully)
Processing Times: License renewals may take up to 8
weeks. Allow sufficient time so that you are not workingwith an
expired license. It is illegal to work without a valid, unexpired
license.
If you have a name change, please include a current copy
of government-issued photographic identification (e.g.,
driver’slicense, passport, alien registration, etc.) AND one of the
following: certified court order, marriage certificate, dissolution
marriage, certified declaration of domestic partnership, or
notarized document verifying name change.
LICENSEE CERTIFICATION I certify under penalty of perjury
under the laws of the State of California that all statements
furnished in connection with
this application are true and accurate and that I have not
changed my address for the purpose of fraud.
Signature of Applicant Date
BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY – Governor
Edmund G. Brown Jr.
Board of Barbering and CosmetologyPO Box 944226, Sacramento, CA
94244P (800) 952-5210 F (916) 575-7281 |
www.barbercosmo.ca.gov
FOR CASHIERING USE ONLY
$________________ Rec. # _______________
ATS # ___________ Postmark Date _________
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INFORMATION COLLECTION, ACCESS AND DISCLOSURE
*This statement is for your information.
The Information Practices Act, Sec. 1798.17 Civil Code, requires
the following information to be provided whencollecting information
from individuals.
AGENCY NAME:
Board of Barbering and Cosmetology
TITLE OF OFFICIAL RESPONSIBLE FOR INFORMATION
MAINTENANCE:Executive Officer
ADDRESS:2420 Del Paso Road, Suite 100, Sacramento, CA 95834
INTERNET ADDRESS:
www.barbercosmo.ca.gov
TELEPHONE AND FAX NUMBERS:
(916) 574-7570 phone (916) 575-7281
AUTHORITY WHICH AUTHORIZES THE MAINTENANCE OF THE
INFORMATION:Sections 7300 to 7457, inclusive, comprising Chapter 10
Division 3, of the California Business and Professions Code.
CONSEQUENCES OF NOT PROVIDING ALL OR ANY PART OF THE REQUESTED
INFORMATION:It is mandatory that you provide all information
requested. Omission of any item of requested information will
result inthe application being rejected as incomplete.
PRINCIPAL PURPOSE(S) FOR WHICH THE INFORMATION IS TO BE USED:The
information requested will be used to determine qualifications for
licensure or certification to determine compliancewith the group
and corporate practice provisions of the law and to establish
positive identification.
ANY KNOWN OR FORESEEABLE DISCLOSURES WHICH MAY BE MADE OF THE
INFORMATION:Your completed application becomes the property of the
board and will be used by authorized personnel to determineyour
eligibility for a license or certification. Information on your
application may be transferred to other governmental olaw
enforcement agencies. Pursuant to the California Public Records Act
(Gov. Code Section 6250 et seq.) and theInformation Practices Act
(Civ. Code Section 1798.61), the names and addresses of persons
possessing a license orregistration may be disclosed by the
department unless otherwise specifically exempt from disclosure
under the law. Consequently, the personal name and address
information entered on the attached form(s) may become
publicinformation subject to disclosure
SOCIAL SECURITY NUMBER (SSN) DISCLOSURE:Disclosure of your
social security number is mandatory. Section 30 of the Business and
Professions Code and PublicLaw 94-455 [42 U.S.C.A. Section
405(c)(2)(C)] authorize collection of your social security number.
Your social securitnumber will be used exclusively for tax
enforcement purposes, for purposes of compliance with any judgment
or orderfor family support in accordance with section 17520 of the
Family Code, or for verification of licensure or examinationand
where licensure is reciprocal with the requesting state. If you
fail to disclose your social security number, you will breported to
the Franchise Tax Board, which may assess a $100 penalty against
you.
